Since the classic paper published by Crohn and colleagues in 1932 describing the chronic inflammatory process of the bowel there have been multiple articles published on the complications of this illness. The description of perianal fistula was followed 6 years later with the incorrect concept that the inflammatory process extended from the bowel down to the perianal area.
The first step in the management of perianal Crohn’s disease is usually the institution of antibiotics. Although there have been several control trials looking at the efficacy of metronidazole in the treatment of active Crohn’s disease, none of them have randomized for fistula response. Because there are no controlled trials showing efficacy we must rely on open-label studies and personal experience.
The first, and most important, diagnostic modalities are clinical history and physical examination by the practicing gastroenterologist. The development of large anal tags (often referred to as “elephant ears”) is associated with Crohn’s disease in the perianal area. Fistulas may hide between these large folds, but the patient should either have had a rectal abscess or have pain and stricturing on physical examination.
The goal of treatment for active Crohn’s disease is to achieve remission.
Crohn’s disease is an inflammatory condition of the bowel that can affect the gut tube anywhere from the lips to the anus. The commonest site of pathology, however, is the small bowel, and this is indeed the focus of most surgical therapy. Other sites, such as the colon and the duodenum, present unique challenges.